Women s Involvement in UNRWA Family Planning Services: A Study of Palestinian Refugees in Jordan

Transcription

1 SIT Graduate Institute/SIT Study Abroad SIT Digital Collections Independent Study Project (ISP) Collection SIT Study Abroad Fall 2014 Women s Involvement in UNRWA Family Planning Services: A Study of Palestinian Refugees in Jordan Madelyn B. Goodman SIT Study Abroad, mgoodm21@jhu.edu Follow this and additional works at: Part of the Medical Education Commons, Public Health Education and Promotion Commons, and the Women's Health Commons Recommended Citation Goodman, Madelyn B., "Women s Involvement in UNRWA Family Planning Services: A Study of Palestinian Refugees in Jordan" (2014). Independent Study Project (ISP) Collection. Paper This Unpublished Paper is brought to you for free and open access by the SIT Study Abroad at SIT Digital Collections. It has been accepted for inclusion in Independent Study Project (ISP) Collection by an authorized administrator of SIT Digital Collections. For more information, please contact digitalcollections@sit.edu.

2 Women s Involvement in UNRWA Family Planning Services: A Study of Palestinian Refugees in Jordan Madelyn B. Goodman Johns Hopkins University Public Health Studies & Biology Major SIT Jordan: Community Health and Development Academic Director: Abdulhaq, Bayan, Ph. D Project Advisor: Mohammad, Khitam, Ph. D Public Health Studies Advisor: Lisa Folda, MHS Submitted in Partial fulfillment of the requirements for Health & Community Development SIT Study Abroad Fall 2014

3 Goodman, 2

4 Table of Contents Acknowledgements... 4 Abstract... 5 Introduction... 6 Literature Review... 8 Methods Design Data Collection Obstacles Results Interviews Material Culture Discussion Conclusion References Goodman, 3

5 Acknowledgements I would like to thank so many people for helping me complete this independent study project. First and foremost, I would like to thank Dr. Bayan Abdulhaq for going above and beyond everyday to help her students succeed. I would also like to thank my advisor for this project, Dr. Khitam Mohammad for taking the time out of her own busy schedule to give me suggestions on how to improve my work. I would like to thank Dr. Lisa Folda, Dr. Lori Citti and Dr. Carly Emerson for their help and support navigating the HIRB approval process at Johns Hopkins University. I would like to thank Dana Dawod, Hamzeh Rasheed, Mustafa Abdo, and Riham Al-Naimat for helping me translate documents and interviews from English to Arabic, or from Arabic to English. Finally, I would like to thank my parents for always encouraging me to think independently and teaching me the important values of respect for all humans and cultures. Goodman, 4

6 Abstract Jordan s total fertility rate has remained stagnant at 3.5 births per woman since the early 2000s (Malkawi, 2013). Palestinian refugees make up 20% of the population of Jordan, significantly contributing to this fertility rate (Jordan: UNRWA, 2014). The purpose of this study was to investigate the perceived level of voice Palestinian women have in family planning counseling at UNRWA clinics and how this perception influenced the success of the counseling. The research was built on the hypothesis that a low level of patient input and consultation during family planning counseling appointments at UNRWA clinics contributed to the stagnated fertility rate. This hypothesis was investigated to offer UNRWA family planning providers information on how to best improve the quality of services. In order to gather accurate perceptions held by Palestinian women, indepth interviews were conducted with patients at an UNRWA family planning clinic. Additionally, an interview with a family planning nurse was conducted to find out more about the services offered at the clinic. Brochures available to patients at clinics were also analyzed to get an idea of the information available to patients about contraceptive methods offered to them. The interviews and analysis of material culture revealed a high-perceived level of voice in family planning counseling at UNRWA clinics, however, societal pressures proved to be the greatest obstacle for Palestinian women to effectively and freely utilize family planning services. This finding allows for more research to be done on the sources of societal pressures and how they influence decision-making concerning family planning. Keywords: public health, family planning, modern contraceptives, refugees Goodman, 5

7 Introduction Family planning is considered by some to be one of the greatest public health triumphs of the twentieth century. The World Health Organization (WHO) defines family planning as [allowing] individuals and couples to anticipate and attain their desired number of children and the spacing and timing of their births. It is achieved through contraceptive methods and the treatment of involuntary fertility. Modern contraceptive methods are synthetic methods used to prevent pregnancy after sexual intercourse. Modern contraceptives do not include traditional contraceptive methods, such as withdrawal, the rhythm method, and standard days method. Modern contraceptive methods can effectively aid in: preventing sexually transmitted diseases, ensuring healthy birth intervals, and empowering women to have control over their reproductive patterns. Family Planning has become a key for the success of development in the twenty-first century as it reduces the rate of population growth and allows women to be active members of the work force. An important element of Arab culture is large family sizes. This is seen in Jordan s total fertility rates: ranging from 4.0 births per woman in the rural Badia to 3.8 births per woman in non-badia areas as of 2007 ("Jordan: 2007 Population and Family Health Survey Key Findings", 2007). Jordan s current overall total fertility rate is 3.5 births per woman; however, it has stagnated around this level since 2002 (Malkawi, 2013). This trend is worrisome, as Jordan s natural resources continue to be strained by its relatively high population. Jordan s natural resources are very sensitive to such population growth; this is due to their scarcity, as Jordan is the 4 th poorest country in the world in terms of water resources. Thus demonstrating the importance of the use of modern contraceptives. The feelings of women receiving family planning services are of utmost importance when it comes to the success of family planning. It is the researcher s opinion that women and women only should have control over their bodies, especially when it comes to fertility. This being said, the level of voice women Goodman, 6

8 perceive to have in their family planning services is essential to the level of quality of such services, as women should be the main decision makers. Previous literature has found a correlation between the quality of family planning services and the rate of use of said services. While Jordan s total fertility rate has stagnated, the use of modern contraceptive methods has decreased and the use of traditional methods has increased. It is important to look into the quality of family planning counseling in order to address the issue of the high and stagnant total fertility rate of 3.5 births per woman, especially since the world s total fertility rate is 2.5 births per woman as of Finding the gap in the quality of family planning services in Jordan, which is preventing the country from further lowering the total fertility rate, is of utmost importance in order to one day lower the rate to that of developed countries, 1.7 births per woman (Malkawi, 2013). Palestinian refugees seeking family planning services at UNRWA clinics in Jordan serve as an ideal study population as the Palestinian community is an accurate microcosm of the larger population of Jordan. This study hopes to find at least one gap in service quality contributing to lowering rates of modern contraceptive use and a stagnated total fertility rate. Two questions were used to frame this research: do Palestinian women perceive their voices are heard in family planning counseling at UNRWA clinics? And, how does this perception influence the success of the counseling? Previous literature has found that patient satisfaction is key in the continued and accurate use of contraceptives. This study s hypothesis was that a low level of patient input and consultation during family planning counseling appointments at UNRWA clinics is to blame for the stagnant fertility rate. The data was collected at the Amman Town Healthcare Center in Amman, Jordan. Five patients and one senior staff nurse were interviewed. Material culture collected from the Amman Town Health Center and the family health center in the Marka camp was analyzed as well. The desired level of depth of the study was not possible to achieve due to time constraints and the ability to obtain approval from UNRWA for further interviews and surveying. Goodman, 7

9 Literature Review In 1916 public health nurse Margaret Sanger opened the first family planning clinic in Brooklyn, New York. After being shut down by the police, several court proceedings set a legal precedent that allowed physicians to provide advice on contraception for health reasons (Achievements in Public Health, : Family Planning, 1999). Family planning as a public health practice has come a long way since then. Rapid population growth is now a global health issue and communities all over the world are beginning to use family planning services and contraceptives. The Jordan National Reproductive Health/Family Planning Strategy states that rapid population growth is detrimental to the country due to already limited natural resources, low economic growth, and environmental stress (2013). Family planning services in Jordan are important now more than ever as the population of Jordan is projected to double to 13 million people in 30 years. Family planning is important for environmental, economic, social, and healthrelated reasons. Long acting contraceptive methods can save $7 in costs from unintended pregnancies for every $1 spent on the contraceptive method (Tsui, A. O., et al, 2010). Not only families, but also entire communities and countries feel this positive economic impact. The use of family planning has lasting impacts on both the mother s and the child s health. Contraceptives can prevent unwanted pregnancies and lengthen internals between births, aiding a woman with spacing her pregnancies. Appropriately spaced births are essential for maternal health. Women with short birth intervals, 24 months or fewer, are more likely to experience birth complications such as proteinuria, bleeding, edema, premature rupture of membranes, preeclampsia, and high blood pressure. Furthermore, if non-first order births were all spaced by two years, infant mortality would be reduced by 10% and child mortality would be reduced by 21% (Yeakey, M. P., et al, 2009). Appropriate spacing of births can help save the lives of both mothers and children. Goodman, 8

10 Use of modern contraceptive methods has stagnated in Jordan at 42%. There has been an increase, however, in those seeking to use traditional family planning methods. This increase in demand can be attributed to the economic burden of large family sizes, more social acceptance of smaller families, higher education levels of women, and shifting familial roles (Users of Traditional FP Methods Needs Assessment, 2014). These shifting familial roles refer to the increasing number of women in the work force in Jordan. Jordan passed a policy to facilitate school-to-work transitions for females. This is important to bolster the labor market as 26.5% of women with a bachelor s degree are unemployed, as compared to 9.1% of men (Yamouri, N., 2010). Including women in the labor market is a key to development. Family planning helps allow women to fulfill their roles as both mothers and as primary players in the economy, benefitting the country as a whole. There are still some societal and ethical barriers to families in Jordan implementing family planning services. Men in particular have limited involvement in family planning services. Several factors have been found to contribute to this, including, perceived side effects disrupting sexual activity, limited family planning methods for men, perceptions of reproductive health as a women s-only issue, preferences for large family sizes, and concerns that the use of contraceptives will lead to extra-marital relationships by the woman (Kabagenyl, A., et al, 2014). Furthermore, factors such as social restrictions and influences, lack of knowledge about its importance, overestimation of side effects, low education levels of communities, and method mis-use and failure leading to negative word of mouth all act as challenges to universal implementation of family planning counseling in Jordan (Users of Traditional FP Methods Needs Assessment, 2014). Many of these barriers are due to misinformation and low quality of care. Use of contraceptives, however, is not a singular issue. Contraceptive prevalence in a country does not necessarily mean correct and consistent use (Tsui, A. O., et al, 2010). For family planning to be truly effective in practice, the administration of services must be of the highest quality. In a USAID report on Goodman, 9

11 how user perceptions of family planning services correspond to objective measures of quality, it was found that, perception of family planning facilities have the key effects on whether a potential client is a user or non-user of a facility, (Speizer, I. S., et al, 2000). Thus, client opinion holds weight on the success of family planning counseling in a community. Friends, neighbors, and family members have been reported at high rates to be the main sources of information about family planning in Jordan (Hamdan-Mansour, A. M., 2009). Word-of-mouth is a direct influence on the use of family planning throughout Jordan; therefore, a clinic of low quality is likely to stifle clientele as word of the poor service spreads. The same USAID study found that facilities perceived to be of better quality were often associated with greater contraceptive use in the surrounding community (Speizer, I. S., et al, 2000). Not only do quality services increase the rate of contraceptive use, but they also raise the odds of continued use of contraceptives. There is a direct link between poor quality of services and contraceptive discontinuation. This makes quality services of utmost importance as total unwanted fertility rates would be between 44 and 81% lower in the absence of contraceptive discontinuation and failure (Steele, F., et al, 2001). In Jordan s National Reproductive Health and Family Planning Strategy it is highlighted that quality of care in family planning services in Jordan faces many challenges including; provider bias, poor counseling, and too few female service providers to meet demand (2013). In 1990 Judith Bruce wrote a paper in the Journal: Studies in Family Planning entitled Fundamental Elements of the Quality of Care: A Simple Framework, outlining six critical aspects of family planning services that clients experience: choice of methods, information given to users, technical competence, interpersonal relations, follow-up or continuity mechanisms, and appropriate constellation of services. She also specifies the three vantage points from which to perceive quality: the structure of the program, the service-giving process itself, and the outcome of care (Bruce, J., 1990). From the vantage point of the service-giving process it is possible to evaluate choice of methods, the information given to users, and interpersonal relations. Goodman, 10

12 Choice of methods refers to number of methods offered, how methods serve important subgroups (age, contraception intention, lactation status, health profile, etc.), and the consistent availability of said methods (Bruce, J., 1990). Other than simple satisfaction from receiving one s preferred method, having a wide range of method choices available to women is important, as women in different life stages require different types of contraceptives. The United Nations Population Fund (UNFPA) recommends nine methods to be available in refugee situations. These methods include: 1. Barrier methods (male latex condoms) 2. Combined-oral-contraceptives (COCs) 3. Progesterone-only pills 4. Injectables 5. Intrauterine-Devices (IUDs) 6. Natural method counseling 7. Breast feeding 8. Hormonal implants 9. Voluntary surgical contraception (Reproductive Health in Refugee Situations: an Inter-agency Field Manual, 1999) Having many contraceptive method choices available increases the overall costeffectiveness of the use of contraceptives (Tsui, A. O., et al, 2010). This increased cost-effectiveness is due to the higher likelihood of continuation of contraceptive use and satisfaction with the chosen method if chosen from a larger pool. A USAID funded study found user method choice to be determined by ease of continuation, risk of failure, and intended length of use (Steele, F., et al, 2001). The more methods offered to a client, the more likely they are to be satisfied with the method they end up choosing and the more satisfied they are with their chosen method, the higher the likelihood of success. Information given to users refers to information imparted during providerpatient contact during the administration of services. This can include how to employ contraceptives with technical competence, the range of methods available to the client, advantages and disadvantages of each method, impact on Goodman, 11

13 sexual activity, and side effects (Bruce, J., 1990). A Jordanian-USAID study on ministry of health service provider s knowledge of side effects of contraceptives, found that 10% of physicians and 18% of midwives advised clients to discontinue use of contraceptives due to normal side effects. Said providers scored an average 71.9% on an exam about side effects of IUDs and COCs. Only 50% of IUD users and 33% of COC users who returned to tested clinics complaining of side effects were told they were normal and to continue normal use (Bitar, N., et al, 2008). There is a clear lack of knowledge of normal side effects from contraceptives on the part of providers in Jordan. Providers proficiency in their knowledge of side effects is the first step to ensure clients receive accurate and clear information about their care. Clear and accurate information about chosen family planning methods is pertinent to continued use of a chosen method. A key indicator for continuity of care is if the provider gives the client instruction to return to the family planning facility for follow-up care (Bessinger, R. E., et al, 2001). The best way to raise awareness of the positive aspects of family planning services, however, and to ensure technical competence in the employment of contraceptive methods is by relaying information into the community through high schools, home visits, healthcare centers, and universities (Hamdan-Mansour, A. M., 2009). Clear and accurate communication of information is the best way to ensure correct and consistent use of family planning. Interpersonal relations, according to Bruce, refers to the family planning program as a whole. In this analysis it will be interpreted as the nature of interactions between clients and providers. Whether appointments are two-way conversations and discussions, or rather a lecture by the provider. Ideally, the client must actively participate in discussion and the ultimate selection of the contraceptive method. The client should feel empowered throughout the counseling experience. The provider must ask the client their reproductive intentions and discuss which method the client prefers to receive prior to prescribing a method (Bessinger, R. E., et al, 2001). Essentially, the family planning counseling should be client-centered. Goodman, 12

14 Women s own perceptions of their voices being heard are of utmost importance to their satisfaction in family planning services. All of the above mentioned studies have neglected to investigate the feelings of those using the family planning services and their level of satisfaction with the services within the Bruce quality of services framework. I hope to discover ways that family planning services can be improved for Palestinian women in UNRWA clinics by consulting those benefitting from them in order to increase their satisfaction with services while also increasing the likelihood of success of said services. Data will be evaluated within the Bruce framework discussed above. Methods Design The purpose of this study is to find a potential gap in the quality of family planning services at UNRWA family planning clinics that is to blame for the stagnated total fertility rate across Jordan. Two methods of data collection were utilized in this study: in-depth interviews with family planning clients and providers and analysis of material culture in the form of brochures found at family planning clinics. Two populations were interviewed in this study to investigate the level of voice Palestinian women have in family planning consultations. The first population was family planning clients at the Amman Town Health Center. Palestinian women at UNRWA clinics were chosen to be the target population for this study due to a recommendation by the project advisor of this study. This recommendation was based on the facts that the Palestinian population in Jordan serves as a very accurate microcosm of trends that exist in the larger population. Furthermore, the total fertility rate among the Palestinian population has rapidly decreased since their arrival in Jordan. This demonstrated the competency of UNRWA services in this area. The second population is the nurse staffing the family planning services at the clinic. This population was chosen in order to investigate the quality of services from the provider s point of view, to Goodman, 13

15 obtain data on the amount of training required of providers, and to quantify the variety and availability of contraceptives at the clinics. These populations were contacted through Dr. Ishtaiwi Abuzayed, the chief of field health programs at UNRWA. Dr. Ishtaiwi authorized the researcher to contact patients and nurses only at the Amman Town Health Center. Patients were interviewed if they had consultation appointments on the morning of November 25 th. At the beginning of their appointments, patients were asked if they would like to participate in the study. All communications between the researcher and participants went through an Arabic to English translator. All interviews, both the patient interviews and the staff nurse interview, were conducted in the Amman Town Health Center in the closed off family planning appointment room. Since interviews took place at the patient s normal appointment time, no one outside the room knew if the patient participated in the research or not. All in-depth interviews were audio-recorded on the researcher s laptop. No names of participants were recorded with the interviews and all recordings were destroyed upon completion of data analysis in order to ensure participant confidentiality. Material culture analyzed in this study was collected from two sources. During a program-organized trip to the UNRWA family health center at the Marka Camp in Amman, brochures were collected from the family planning clinic. On the same occasion that interviews were conducted, brochures available at the Amman Town Health Center regarding family planning were collected for later analysis. Material culture was analyzed based on criteria for quality information given to users as outlined in the Bruce framework. Material culture was scored as poor, good, or excellent based on elements present. Sought after elements included: advantages, disadvantages, side effects, instructions for use, and possible scientific contraindications. Advantages, disadvantages, and side effects were considered as essential elements to the quality of the material culture. Brochures containing these elements were scored as good quality. Material culture containing instructions for use or possible scientific contraindications in Goodman, 14

16 addition to the previously mentioned elements of good quality material culture were scored as excellent quality. Material culture missing all of these elements was scored as being of poor quality. Data Collection 1. During a program-scheduled visit to the UNRWA field offices, contacts were made with the chief field health officer, Dr. Ishtaiwi, and a senior staff nurse at the family health center in Marka camp. 2. Brochures with information on family planning methods were collected during a program visit to a family health center in the UNRWA Marka camp. 3. In a meeting with Dr. Ishtaiwi at the UNRWA field offices approval was attained to conduct research at the UNRWA clinic: The Amman Town Health Center. Additionally, the researcher was informed that only five patients and one staff nurse were to be interviewed. 4. Dana Dawod was contacted about translating interviews. During this meeting arrangements for her to translate the interview guide and informed consent form into Arabic were also made. 5. Once the research was officially approved through UNRWA, the contact information for Dr. Mohammad, the head physician at the Amman Town Health Center, was received. 6. Contact was made with Dr. Mohammad and a date and time was set to visit the Amman Town Health Center to conduct interviews. 7. Interviews were conducted with five patients attending the family planning clinic at the Amman Town Health Center and the nurse staffing the health center. Interviews were translated from Arabic to English by Dana Dawod. 8. After interviews were conducted, more material culture was collected from the health center. 9. The English translations of the participant s responses were transcribed from recordings of the interviews. 10. Interviews and material culture were analyzed based on the quality of family planning services framework outlined in the Bruce framework. Goodman, 15

17 All those interviewed signed an informed consent form explaining the research and the participant s rights to refrain from participating or rescinding their responses. The informed consent form was written in Arabic. The interviewer, with the assistance of the translator, verbally confirmed the participant s permission for the interview to be recorded. All recordings of interviews were destroyed upon completion of data analysis. All research was conducted after being approved by the Local Review Board, UNRWA headquarters, and the Institutional Review Board at Johns Hopkins University. Obstacles There were several obstacles to overcome while conducting this research. Receiving approval from all appropriate agencies was the most challenging of the obstacles. Approval from the Local Review Board in Jordan was the most straightforward process. This approval was attained at the earliest opportunity. After the initial submission of the research proposal and relevant forms, only modest revisions were required before approval was obtained. After review of the research proposal, the chief officer of UNRWA s field health programs approved the project. With this approval, however, came the stipulations that only five patients and one nurse were allowed to be interviewed at one health center. These stipulations restricted both the depth and the scope of the study. Additionally, the researcher planned on conducting surveys of family planning nurses at many different health centers. UNRWA, however, did not approve these surveys to be distributed. Questions from the surveys were added to the interview guide of the provider interview. Brochure analysis for the quality of information provided to patients was chosen as the second data collection method. All research materials: proposal, interview guide, informed consent form, and research outline, were sent to the Johns Hopkins Institutional Review Board for review a month before data collection was to begin. After a week of preparation for data collection the researcher was contacted to fill out a full electronic Homewood Institutional Review Board application. After a week of ing and revising, the research was officially approved. With all of these strict Goodman, 16

18 measures, however, the researcher was nervous to stray too far from the approved interview guide for fear of disciplinary action by the HIRB. Unfortunately, this meant that few follow up questions were asked. The most unavoidable obstacle was the time constraint on the whole project. There were only four weeks allotted to contact all interviewees, collect data, analyze data, and write the report. Additionally, only one and half weeks to do the report remained after approval from the Hopkins Institutional Review Board was attained. This made it especially difficult to coordinate volunteers to translate both interviews and material culture. Results Interviews Interviewing patients and the nurse in the family planning clinic at the Amman Town Health Center revealed unanticipated trends in the quality of family planning services available to UNRWA patients. Family planning counseling at the Amman Town Health Center displayed a high level of consideration of patient preferences and low provider bias. Indicators of these trends were seen through themes present in interviews with both the patients and the provider. These themes addressed the research questions that framed this study. Responses focusing on topics such as birth spacing, the provider s process to prescribe methods, and the husband s involvement in family planning spoke to women s perception of their voices being heard in the counseling process. In addition, patient s comfort level with UNRWA services and the improved health status of patients due to contraceptives confirmed how the perception of their level of voice influenced the success of the services. Perceptions of how women s voices are heard When asked about their attitude towards family planning services, interviewees demonstrated a high level of knowledge of the advantages of using contraceptives. Four out of five women interviewed mentioned the health advantages of birth spacing. Five out of five of the women interviewed mentioned Goodman, 17

19 that contraceptives allowed them more time to themselves and more time to take care of their children. The first cause for me to start using contraceptives was to have sufficient distance and time between baby and others. Interviewee 2 at the Amman Town Health Center If you have enough time between the babies you can get some time for yourself, so psychological-wise you can be relaxed, you will be less tired. According to my experience because I have many babies, I need to be working 24 hours per day just to take care of the babies. Interviewee 4 at the Amman Town Health Center This high level of awareness about the advantages of birth spacing demonstrates that patients were well informed about the advantages of using contraceptives. Most patients specified that their knowledge of contraceptives came from the UNRWA family planning clinic. UNRWA service providers empowered their patients by educating them on the advantages of using family planning. This allowed patients to make informed decisions about family planning and contraceptives. If women are empowered with relevant and correct information about the services they can better voice their preferences. Indicators of provider bias at the Amman Town Health Center were very low. In an interview with the senior nurse staffing the family planning clinic, only the patient s preference and her health condition were considered in the prescribing of a contraceptive method. It is according to her preference. I will not communicate my preference to my customers. It is only about the patient s condition. Senior staff nurse at the Amman Town Health Center Throughout the interview the nurse outlined the process by which she prescribes contraceptives. Once the patient voices her preference of contraceptive method, Goodman, 18

20 the nurse discusses any health contraindications with the method for the patient. Additionally she goes over all advantages and disadvantages associated with the method. She explains all related side effects and how to properly use the method. The nurse then gives the patient time to decide which method is best, allowing her to go home to discuss with her family. If the patient s husband does not agree with the use of contraceptives, the nurse will still give the patient her preferred method if she wishes to proceed with family planning. The nurse, however, does not provide condoms to couples when the husband did not agree with the use, as the success of condoms are dependent upon the husband s compliance. Once she prescribes a method she has the patient return to the clinic in one month to ensure everything is going well, then in three months, then every following six months. The provider at this clinic was extremely patientfocused and valued the patient s preference of contraceptive method above all else. This provider s attitude demonstrated the high level to which patient preference and voice was valued in family planning counseling at the Amman Town Health Center. When directly asked about the level of voice patients had in family planning counseling sessions, four out of five women said that the choice of contraceptive was a mutual decision with their husband. Furthermore, all women interviewed said the decision to start the use of modern contraceptives was initially supported by their husbands. My husband was involved with me. After our sixth baby we decided: this is enough, we have many responsibilities, our children s needs, many needs, according to the life needs and they need many things. They have financial needs, something like this, so we decided to start the contraceptives. It was a mutual decision. Interviewee 4 at the Amman Town Health Center This mutual decision-making can be both a positive and negative indicator for women feeling empowered in their decision about contraceptive methods. While a husband s support is imperative for some methods, such as condoms, for Goodman, 19

21 others the husband s opinion can limit the woman s choice. Interviewee 4 mentioned that her husband would not let her use pills for fear of the side effects associated with this method. Fear of side effects impacted the decision-making of four out the five women who were interviewed. These worries about side effects are often addressed in counseling sessions at the clinic. Since none of the women were accompanied by their spouses, their fears of side effects for their wives restrict the women s options of contraceptive methods, often without knowing the facts. The success of family planning counseling Patients volunteered that contraceptives were essential to maintaining their health status in general. Four out of five of the patients interviewed mentioned health status as either a reason they started using contraceptives, or that the use improved their health status. I got my birth on caesarean section so I need to get relaxed, the doctor notified me that I must use contraceptives. Interviewee 5 at the Amman Town Health Center Additionally, most patients could relate the choice of their specific contraceptive method to their health status. Interviewee 1 was not able to use combined-oral contraceptives or an IUD due to hypertension and age, so instead she used condoms. Interviewee 3 was not able to use combined-oral contraceptives due to a heart condition, so she used an IUD. A patient knowing how their method is selected is an essential element to the quality of information given to users (Bruce, J., 1990). This indicated the high level of quality and patient success utilizing family planning counseling at UNRWA clinics. Three out of the five women interviewed used UNRWA clinics for many other services besides family planning. Childcare, vaccinations, noncommunicable disease treatment, and prenatal care were just a few of the other services interviewees utilized. They expressed great comfort with UNRWA service providers. Goodman, 20

22 I am free to say anything to the counselor, there is no barrier between us. Interviewee 1 at the Amman Town Health Center The overall comfort level of patients with the UNRWA family planning providers indicated an environment of openness in counseling sessions. As explained by the staff nurse, patients often return to the clinic with questions or concerns after they receive their prescribed method. This open and relaxed attitude encouraged the success of patients with family planning as they were free to address concerns they had with their current method or change methods if they wished. Material Culture Apart from patient-provider contact, the quality of literature patients have about the contraceptive methods available to them is essential to the quality of services they are receiving. This level of quality greatly impacts the success patients experience with family planning counseling. Outlining potential side effects, advantages, and disadvantages of each method is essential to the quality of the literature. Furthermore, specifying instructions for use and/or possible health-contraindications constitute exceptional literature. The brochure on combined-oral contraceptives collected at the family health center in Marka camp displayed exceptional quality. It warned against the side effects of migraines and high blood pressure while also warning against the contraindication associated with women who are particularly sensitive to estrogen hormone. Instructions for use and what to do if the woman forgot to take a pill were also outlined in great detail in the brochure. The overall contents of the pamphlet were of extremely high quality. The visual aspects of the brochure, however, could use improvement. While at the clinic the researcher observed that almost all of the women attending this clinic covered their heads. The woman pictured in this brochure, however, does Goodman, 21

23 not have her head covered. When drafting brochures UNRWA should take special care to ensure that women pictured reflect the women who will be reading the pamphlet. This will ensure that women can relate to the literature and see themselves being successful using the product. The brochure providing information about Depo-Provera injections displayed higher quality content than the combined-oral contraceptive brochure. Also collected at the family health center in the Marka camp, the brochure outlined side effects, advantages, disadvantages, instructions for use, and possible contraindications in great detail. Not only did two of its panels cover possible side effects, but it also included information about when to visit a physician if the patient experiences complications. Furthermore, it contained advice about using additional methods in the first few days after the administration of the injection to ensure the avoidance of pregnancy. The brochure also contained information about how long after discontinuing use of the method the woman would be able to become pregnant. While its contents were more thorough than the combined-oral contraceptive brochure, it had a similar shortfall: the women pictured in the brochure did not reflect the client base of the clinic. One brochure was collected at the Amman Town Health Center. This brochure contained the most complete information of all the brochures analyzed. Although it covered more methods than were available at the center, it provided complete information on all methods available by both UNRWA clinics and the Jordan Ministry of Health. The section on combined-oral contraceptives explained that the method could help protect from certain cancers, something that was left out of the previous brochure on this method. Furthermore, it clarified that fertility immediately returns when the woman stops taking this method. This brochure also included a section about Goodman, 22

24 choosing the correct method in different situations. Whether the woman is newly married, or is a new mother, the brochure provided culturally appropriate advice for any situation. Another aspect of this brochure that the others left out, was how each method affected sexual relations between partners. While side effects and medical-contraindications are more common worries among couples, it remains important to address all impacts of contraceptives on the functioning of everyday life. All of the literature collected from the UNRWA family planning clinics provided comprehensive information on relevant methods. This information allows women attending the clinics to successfully use these methods by outlining proper instructions for use, side effects, advantages, disadvantages, and possible medical-contraindications of each method. Discussion The results from interviews and material culture analysis does not support the hypothesis that a low level of patient input and consultation during family planning counseling appointments at UNRWA clinics is to blame for the stagnant fertility rate in Jordan. Within the population interviewed, patients felt in control of the counseling process. While the population interviewed is representative of the general population of Jordan, the services available to them may not be representative of those available to the majority of people in Jordan. The hypothesis of this study was formulated after reading literature about family planning services provided by the Jordan Ministry of Health. Services available through the Ministry of Health may differ from those available at UNRWA clinics, Royal Medical Services facilities, and private medical service providers. Thus, shortcomings of the quality of family planning services may be different at each institution. Additionally, each institution serves a different population in Jordan, and each population may face their own unique social limitations. While lack of perceived voice within family planning counseling does not inhibit the success of the counseling, lack of perceived voice outside of the clinic may. Four out of five of the women interviewed at the Amman Town Health Goodman, 23

25 Center mentioned social pressures as a barrier to the use of contraceptives within their society. Interviewee 2 mentioned that the morning of her appointment her husband was pressuring her to remove her IUD so they could have another baby. Interviewee 4 expressed the social pressures her husband faced having married a younger woman: his family expected him to have many children. For this reason, all of the women interviewed started using family planning only after they already had children. In the case of interviewee 4, she and her husband had more children than they desired before starting the use of contraceptives due to pressures from their families. After the birth of their sixth child they started using contraceptives to leave four and five years between the births of their next two children. The interviewee expressed that she preferred this space between children rather than the one or two years that spaced her previous six children. Given the strong impact of social pressures on the accurate use of family planning services, the claim that perception of family planning facilities have the key effects on whether a potential client is a user or non-user of a facility, does not hold true in all circumstances (Speizer, I. S., et al, 2000). Through observations from this study, it is clear that society and family pressures can have a larger influence over a couple to be family planning users or non-users than just the quality of the available facility. Moreover, poor quality of services being directly related to contraceptive discontinuation was not observed either (Steele, F., et al, 2001). Three out of five of the women interviewed mentioned that their husbands started out as supporters of the use of contraceptives, however, as time went on they no longer felt the same way. Interviewees related that their husbands refused to continue using condoms, or they requested their wife remove her IUD. Thus, in the case of the Amman Town Health Center, poor quality of services was not to blame for discontinued use of family planning services, rather, husband or family influence was the main cause. Social pressures influenced some couple s fear of side effects as well. Interviewee 2 stated that she did not start using contraceptives after her first child because of warnings from those in her community that it would inhibit her fertility. Myths about side effects being prevalent in communities act as barriers for Goodman, 24

26 women to feel comfortable using contraceptive methods. The best way to extinguish these myths is to go into the community; through high schools, home visits, healthcare centers, and universities to disseminate accurate information about family planning (Hamdan-Mansour, A. M., 2009). In this study it is clear that social pressures undeniably conflict with the desire to practice healthy birth spacing and to have enough time to care for each child. Thus, said pressures prevented families from having their desired family size. More research is required into the effect of social pressures on the Palestinian community in Jordan to practice effective utilization of family planning services. Finding exactly where these pressures originate and how they influence decision-making about family planning would lead to better-targeted and more effective programs to lower the total fertility rate in Jordan. From conversations with administrators at UNRWA, the Jordan Higher Population Council, and through lectures on the health system in Jordan; it is obvious that the solution to the high and stable fertility rate in Jordan, and among Palestinian refugees in particular, is not singular. Jordan has many different populations of people utilizing health services from different types of sources. While societal pressures are an obstacle to low and healthy fertility rates in the Palestinian community, this may not be the case for other communities in Jordan. For example, the Jordan National Reproductive Health/Family Planning Strategy cites provider bias as a barrier to quality family planning services in Ministry of Health facilities (2013). The issue may be different at Royal Medical Service facilities and private medical facilities. There is no one solution for Jordan to lower its total fertility rate. Specialized work is required in each microcommunity in order to achieve the necessary behavior change. Conclusions Through in-depth interviews with patients and the nurse staffing the family planning clinic at the Amman Town Health Center, and analysis of brochures concerning family planning, it is clear that a high level of patient voice exists in family planning counseling appointments. Thus, this essential element to service Goodman, 25

27 quality is not to blame for the high and stable total fertility rate among Palestinians and the general Jordanian population. This study does not provide an absolute conclusion on the level of voice patients have in family planning programs in UNRWA clinics in Jordan. Limitations of the study include; patients and a nurse from only one family planning clinic were interviewed, only one service provider was interviewed, and saturation of data from interviews was not reached. To achieve a definitive conclusion on this issue, more providers must be interviewed, patients attending different UNRWA clinics must be interviewed, and more UNRWA health care facilities must be investigated. Additionally, a survey of the services offered at different facilities would help to obtain an accurate picture of what is available to patients at UNRWA family planning clinics. While it was found that services at the family planning clinic at the Amman Town Health Center were of high quality, responses from patients revealed that societal pressures act as a barrier to effective and consistent utilization of family planning. After a thorough literature review, the conclusion was drawn that quality of family planning services was thought to be the basis of whether a woman would be a user or non-user and the longevity of her commitment to a modern contraceptive and family planning practices. Through interviews and material culture analysis, however, it has been concluded that for women attending the Amman Town Health Center societal pressures, rather, act more as a barrier to successful use of family planning. Further research is necessary into exactly where these societal pressures originate and how they affect the family s decision to use family planning services or not. Furthermore, research conducted at the different access points of family planning in Jordan and the different sub-populations they serve is necessary to develop sustainable strategies to lower the total fertility rate throughout Jordan. This research must look into what obstacle faces each sub-group in Jordan to achieve a lower fertility rate. As this study has found societal pressures influence Palestinian women to have larger families, similar research is necessary to find if quality of services is the barrier for those attending Ministry of Health facilities, or Goodman, 26

28 if another barrier is effecting those attending Royal Medical Service facilities, or private medical service providers. This further research is necessary in order to know where the challenges are at facilities other than those run by the Ministry of Health in lowering the fertility rate in Jordan once and for all. Goodman, 27

29 References Primary Sources Interviewee 1, Patient at the Amman Town Health Center, 25, Nov. 2014, M. Goodman Interviewer Interviewee 2, Patient at the Amman Town Health Center, 25, Nov. 2014, M. Goodman Interviewer Interviewee 3, Patient at the Amman Town Health Center, 25, Nov. 2014, M. Goodman Interviewer Interviewee 4, Patient at the Amman Town Health Center, 25, Nov. 2014, M. Goodman Interviewer Interviewee 5, Patient at the Amman Town Health Center, 25, Nov. 2014, M. Goodman Interviewer Senior Staff Nurse at the Amman Town Health Center, 25, Nov. 2014, M. Goodman Interviewer Combined-Oral Contraceptive brochure, UNRWA Depo-Provera brochure, UNRWA Comprehensive modern contraceptives brochure, Quality Family Planning Secondary Sources (1999). Family Planning. Reproductive Health in Refugee Situations: an Interagency Field Manual. Retrieved from (2011). UNRWA Response to OHCHR Survey on Technical Guidance to Prevent Maternal Mortality and Morbidity. (2013). Jordan National Reproductive Health/Family Planning Strategy at a Glance. USAID Health Policy Project. (2014). Users of Traditional FP Methods Needs Assessment. Health Systems Strengthening II: USAID Jordan. Achievements in Public Health, : Family Planning. (1999, December 3). Retrieved November 19, 2014, from Goodman, 28

30 Al-Alawi, N. (2010). Evidence-Based Medicine (EBM) for Family Planning Program. USAID. Bessinger, R. E., & Bertrand, J. T. (2001). Monitoring Quality of Care in Family Planning Programs: A Comparison of Observation and Client Exit Interviews. International Family Planning Perspectives, 27(2), pp Bitar, N., & Shahrouri, M. (2008). MOH Service Providers Knowledge on How to Manage IUDs & OCs Side Effects. Health Systems Strengthening: USAID Jordan. Bruce, J. (1990). Fundamental Elements of the Quality of Care: A Simple Framework. Studies in Family Planning, 21(2), pp Hamdan-Mansour, A. M., (2009). Survey Report of Married Men and Unmarried Youth (Female and Male) at the Age Years. Integrating Health and Empowerment of Women in the Southern Region Project. Jordan: 2007 Population and Family Health Survey Key Findings. (2007, January 1). Retrieved from Jordan UNRWA. (2014, January 1). Retrieved from Kabagenyl, A., & Jennings, L. (2014). Barriers to Male Involvement in Contraceptive Uptake and Reproductive Health Services: a Qualitative Study of Men and Women s Perceptions in Two Rural Districts in Uganda. Reproductive Health, 11(21), pp Malkawi, K. (2013, August 29). Jordan succeeds in reducing fertility rate to 3.5 children per woman. The Jordan Times. Retrieved from children-per-woman Speizer, I. S., & Bollen, K. A. (2000). How Well Do Perceptions of Family Planning Service Quality Correspond to Objective Measures? Evidence From Tanzania. MEASURE Evaluation: USAID. Steele, F., & Curtis, S. L. (2001). Appropriate Methods for Analyzing the Effect of Method Choice on Contraceptive Discontinuation. MEASURE Evaluation: USAID. Goodman, 29

31 Tsui, A. O., & McDonald-Mosley, R., et al. (2010). Family Planning and the Burden of Unintended Pregnancies. Epidemiologic Reviews, 32, pp Williams, T., & Schutt-Aine, J., et al. (2000). Measuring Family Planning Service Quality Through Client Satisfaction Exit Interviews. International Family Planning Perspectives, 26(2), pp Yamouri, N. (2010, April 1). Middle East and North Africa: Women in the Workforce. Retrieved November 19, 2014, from XTMNAREGTOPPOVRED/0,,contentMDK: ~pagePK: ~pipk: ~thesitepk:497110,00.htm Yeakey, M. P., & Muntifering, C. J., et al. (2009). How Contraceptive Use Affects Birth Intervals: Results of a Literature Review. Studies in Family Planning, 40(3), pp Goodman, 30

32 Appendix A: Consent to use ISP Appendix Goodman, 31